1. Using Flowcharting to Improve Inefficiencies Marsha Moxley, RN, BSN, MA, CPHQ February 10, 2010 10:15-11:45 AM

2. Learning Objectives By the end of this session, participants will be able to: 1. Identify the three most common shapes used to develop a flowchart. 2. List three different types of flowcharts. 3. Describe the reason for utilizing flowcharting to understand the basic concept of process management.

3. When Should you Use Flowcharting? To gain knowledge & understanding of how the actual system works versus To gain knowledge & understanding of how the actual system works versus ideal system ideal system To identify redundant steps in a system To identify redundant steps in a system to improve performance to improve performance To reduce variation and eliminate waste To reduce variation and eliminate waste to improve the quality & cost of care to improve the quality & cost of care delivery delivery

4. Purpose of Flowchart A flowchart is a picture of the steps (processes) within a system. Flowcharts are utilized to examine the relation and sequence of steps: to identify redundancy, unnecessary complexity, inefficiencies and to create a common understanding of the flow of a system

5. "Flow Chart" is a Snap Shot of your Business Processes. You can tell a lot about the complexity (and often over-complexity) of many business processes just by looking at an as-is flow chart of them - without even reading the text in the symbols. You can tell a lot about the complexity (and often over-complexity) of many business processes just by looking at an as-is flow chart of them - without even reading the text in the symbols. You can easily see the flow of information and materials, branches in the process, opportunities for infinite loops, the number of process steps, inter-departmental operations, and more. You can easily see the flow of information and materials, branches in the process, opportunities for infinite loops, the number of process steps, inter-departmental operations, and more.

6. What is the Difference between a Process and a System? Process: a series of actions that lead toward a particular result Process: a series of actions that lead toward a particular result System: regularly interacting or interdependent group of items forming a unified whole. Methodical in procedural of plan System: regularly interacting or interdependent group of items forming a unified whole. Methodical in procedural of plan Definitions from Webster’s New Collegiate Dictionary

7. Usefulness of Flowcharts In process improvement, flowcharts are often used to clarify how a process/system is being performed or to agree how it should be performed. Assists in standardization of systems as a graphical format for procedures and to assist in training of procedures.

8. Flowcharting Symbols Oval: Represents Start or Stop of process/system. The ovals are the boundaries. Rectangle: Activity Step (s) of a process. Diamond: Decision Points in process flow. Form a question. Each decision should have a “yes” or “no path.

9. Flowcharting Symbols Small Circle: Represents connections in process flow. More than one column or more than one page. 2 Triangle: A step where there is waiting or storage occurs. Example: Admission/discharge waits Arrow: A step where product (or a patient) is being transported. Example: To Therapy or Dialysis

10. If you don’t involve the user, you will develop the wrong system. Brian Joiner

11. Steps to Develop a Flowchart 1. Decide on the system to flowchart. 2. Define the beginning and ending steps of the system. of the system. (These are known as the boundaries) (These are known as the boundaries)

12. Steps to Develop a Flowchart… continued 3. Describe the beginning of the system with an oval. (When developing a flowchart, steps can be written on Post-it (When developing a flowchart, steps can be written on Post-it notes so that the actions can be reordered easily) notes so that the actions can be reordered easily) 4. Ask “What Happens Next”?, each subsequent process step will be in a rectangle shape.

13. Steps to Develop a Flowchart… Continued 5. When a decision step occurs, use a diamond shape for the questions. Write yes / no and develop a path for each. ( Make sure each decision loop reenters the system or is ( Make sure each decision loop reenters the system or is pursued to a conclusion) pursued to a conclusion) 6. Describe the ending step in an oval. Sometimes, due to the branching at decision points, Sometimes, due to the branching at decision points, a system may have more than one ending boundary, a system may have more than one ending boundary, especially when it is a complex “super’ system. especially when it is a complex “super’ system.

14. Things are the way they are simply because that got that way…. It’s always been done that way….

15. Examples of the Various Types of Flowcharts

16. Common Names for Flowcharts: Process Flow Chart Process Flow Chart Process Map Process Map Process Chart Process Chart Business Process Model Business Process Model Process Model Process Model Process Flow Diagram Process Flow Diagram Work Flow Diagram Work Flow Diagram Business Flow Diagram Business Flow Diagram

17. Top Down Flowchart Step 1: Plan To Write AHCA Application Step 2: Organize /assign Roles & set deadlines Step 3: Submit the darn 1.1 Assess if eligible to apply 1.2 Review AHCA Application 1.3 Attend Workshop 1.4 ETC…… 2.1 Copy of application to team 2.2 Assign sections for content experts 2.3 Set deadlines for completion 2.4 Review data, decide improvements 2.5 Assign graphs – review options 2.6 Assign 1 writer 2.7 Assign reviewer for English, sentence structure and grammar 2.8 ETC……. 3.1 Get Final clean copy from writer 3.2 Credit card approval 3.3 Submit on-line 3.4 Go out and celebrate!

18. Workflow Diagrams - Before

19. Workflow Diagrams - After

20. Alarm Goes Off Can I hit the snooze button? Go back to Sleep Get OOB & turn off alarm Let the Dog Out Take A Shower Start Coffee Turn on TV & listen to News A A Blow Dry Hair Decide what to wear Any special meeting? Get dressed & put on jewelry Apply makeup 1

21. Change would be easy if it weren’t for all the people

24. YES Assess change in risk status by weekly skin assessments, change of condition, etc. *See below change of condition criteria NO YES Is pressure ulcer present? 1. Discuss risks with resident and family/Risk brochures 2. Implement immediate interventions. 3. Develop individualized care plan. Risk Identification/Prevention New Admission/Re-admission Complete 24hr Admission Assessment 1. Skin assessment to be 1 st section completed 2. Compare assessment findings to risk factors on IPOC. Pressure Ulcer Flow Diagram Pressure ulcer identified from admission skin assessment/weekly skin assessment/observation. Implement resident specific interventions immediately: Specialty mattress/pressure reduction mattress on bed Pressure reduction cushion in wheelchair Treatment as ordered Individualized repositioning *See Pressure Ulcer Guideline and IPOC Plan of Care/Communication Initiate IPOC – BE565 and place individual resident interventions and mark problems/risk factors Notify family and document notification Notify: Dietary Activities Social Services Treatment: Actions/Steps Notify physician and document notification Input MD order/treatment into Vista Keane system Print new treatment order and place on Treatment Administration Record (TAR) Initiate BE598C – Pressure Ulcer Report and document initial assessment of pressure area including: Location and staging Size (length x width/depth) presence and location of undermining and tunneling Edudate/if present” type, color, odor, and approximate amounts Pain/if present: nature and frequency Wound bed: color & type of tissue/character including/character including evidence of healing (granulation) or necrosis (slough and eschar). Description of would edges and surrounding tissue Reassess, re-evalute and revise interventions when progress is not note within 14 days. *Change of Condition criteria: May include the following: Bed Mobility Problem Bedfast Bowel incontinence Previous Ulcer Skin desensitized to pain or pressure Daily Restraint

25. Flowchart Resolution

26. National Patient Safety Foundation’s (NPSF) Philosophy Most errors are a result from faulty Systems rather than human error, e.g., poorly designed processes that put people in situations where errors are more likely to Be made. Those people are in essence “set up” to make errors for which they are not truly responsible”.

27. Let’s Give It A Try!

28. Developing Flowchart Tips Use post-its & sharpies /markers (Visible) Use post-its & sharpies /markers (Visible) Doesn’t have to be in a meeting room - Doesn’t have to be in a meeting room - go to Nursing Station and put each process go to Nursing Station and put each process on a post-it note on a post-it note Use flipchart paper / ability to switch steps easily Use flipchart paper / ability to switch steps easily Ask those that work in the system to validate the flowchart is accurate versus ideal Ask those that work in the system to validate the flowchart is accurate versus ideal

29. Common Questions to ask the User of the System? “What do you do first?” “What do you do first?” “What happens next?” “What happens next?” “Is it always that way?” “Does it ALWAYS work this way?” “Is it always that way?” “Does it ALWAYS work this way?” “Do you sometimes do something else?” “Do you sometimes do something else?” “Is there ever any problems you experience because of lack of training or supplies or equipment?” “Is there ever any problems you experience because of lack of training or supplies or equipment?”

30. Case Study / Group Exercise Instructions: Flowchart a Falls System 2. Decide Who Will Debrief To All 3. Have Some Fun!

31. Flowcharting Software Word /PowerPoint/Excel draw function Word /PowerPoint/Excel draw function www.Smart.draw.com www.Smart.draw.com www.Smart.draw.com www.breezetree.com www.breezetree.com www.breezetree.com www.edrawsoft.com www.edrawsoft.com www.edrawsoft.com www.springcape.com www.springcape.com www.springcape.com “Google” Flowcharting and you will be amazed!

32. References www.Smart.draw.com www.Smart.draw.com www.Smart.draw.com www.breezetree.com www.breezetree.com www.breezetree.com Webster’s New Collegiate Dictionary The Team Handbook, Joiner, 5 th Ed., 2001 The Team Handbook, Joiner, 5 th Ed., 2001 Root Cause Analysis: Simplified Tools and Techniques, Bjorn Anderson, Tom Iagerhaug, Milwaukee, WS, ASQ Quality Press, 2000. Root Cause Analysis: Simplified Tools and Techniques, Bjorn Anderson, Tom Iagerhaug, Milwaukee, WS, ASQ Quality Press, 2000.

33. Questions? Thank you! Marsha Moxley Cell: 407-247-8814